Transcript

Norman Swan: Hello and welcome to the Health Report with me, Norman Swan.

Today: 150 things that are done or ordered by doctors in the Australian healthcare system which are often unnecessary or even potentially harmful with little benefit. There are millions of dollars being wasted which could be better spent, but how to get more rational use of these tests and treatments? Listen on.

Plus, steroids: cortisone-like drugs which dampen inflammation, not the steroids which build muscles. Corticosteroids, such as prednisone which are frequently used in spinal injections for back pain. So, do they work? And if not, what does work in back pain? Plus, rather amazingly, a recent review of the available evidence which suggests steroids might be worth a go in severe sore throats.

Paul Glasziou is Professor of Evidence-Based Practice at Bond University in Queensland.

Paul Glasziou: Chris Del Mar and I have for a long time been interested in the effectiveness of antibiotics for sore throats, and realised that they have been over-prescribed, over-used. There are some circumstances where they are needed, but we also became interested in alternatives to antibiotics for sore throats. So we've got a separate review that looked at a number of alternatives to antibiotics for sore throats. And what jumped out at us I think was that probably the most effective thing was oral corticosteroids, just a short course of them.

Norman Swan: Who came up with that idea?

Paul Glasziou: In a sense it's an old idea. I can remember as a medical student one of the treatments for very severe sore throat from glandular fever, to the point where you couldn't swallow, was to have steroids. But we were, I think, increasingly recognising that some of the damage done from acute infections is done by the immune system, it is not the bacteria or the virus themselves, it's our reaction to them, and the steroids help dampen down that extreme end of the reaction.

Norman Swan: So you looked for randomised controlled trials, placebo-controlled trials that have tested whether or not steroids help.

Paul Glasziou: That's right, and we found several of those. For most endpoints, it was six studies that were included, I have to mention that all of those were with a background of antibiotic cover, so both groups received antibiotics, but then half the group received corticosteroids and half received placebo.

Norman Swan: How many doses?

Paul Glasziou: These are typically 20 mg orally of prednisone would be a typical dose. Some of them were using intramuscular doses as a single dose. Some of them were using oral steroids for a few days. But they were all short-term steroids. We're talking about either a single dose or a few days.

Norman Swan: And these trials were in adults as well as children?

Paul Glasziou: Yes, so some of them were adults, some of them were children and some of them were both.

Norman Swan: And what were the findings?

Paul Glasziou: The overall findings are that corticosteroids are effective when you've got a very severe sore throat and that that kicks in relatively early. So you get pain relief within the first day, probably maximum by about day two or three, and that is earlier than you get with the effect of antibiotics. So if you've got a very sore throat to the point where you're finding it very difficult to swallow, corticosteroids are really the thing that give you that fairly quick relief.

Norman Swan: And these people with the sore throat, were they bacterial or viral sore throats, or were they just given the antibiotics blind in the hope that they might help?

Paul Glasziou: It was a bit of a mix, Norman. In some of them they'd actually tested to see whether they had the bacterial sore throat, the streptococcus. In others they used the criteria that suggested it was bacterial, but we know with the threshold that they used that it's probably about a 50/50 mix. So you’re actually getting the effect in both of those groups.

Norman Swan: And was there any evidence that the effect of steroids was greater in people with a bacterial sore throat or a virus or vice versa?

Paul Glasziou: No, I don't think it makes much difference, it is the degree of inflammation that matters and it's knocking off that inflammation, it doesn't matter whether it's caused by a virus or bacteria.

Norman Swan: And what complications?

Paul Glasziou: There were none recorded in the studies, but the one warning I'd have is that in general short-term corticosteroids are pretty safe, but the major side-effect that you do get, not reported in these studies but from other studies, is the psychiatric side-effects. Some people just feel a bit euphoric or dysphoric from it, and occasionally you'll get a person with an acute manic episode, for example. So there is a small risk and I wouldn't take this lightly unless you had a very severe sore throat that you needed treated.

Norman Swan: The problem here of course for the cost for the system is that you're talking here about one or two doses of steroids and a GP having to give a prescription for a whole bottle of them.

Paul Glasziou: But the cost of steroids is pretty low compared with the consultation fee. I don't see that as the major problem here. If someone is coming in with a sufficiently sore throat that it requires steroids, then there are bigger cost to the medical system from other ways of treating it. However, the thing I'd say is that for most people with a sore throat, if you want pain relief you could just use over-the-counter medication.

Our other review, not this one, looked at non-steroidal anti-inflammatories, things like Nurofen that you can get over the counter, and they are also effective. There is no head-to-head comparison saying whether those, the Nurofen anti-inflammatories compared with corticosteroids as an anti-inflammatory are more effective, we can't tell. I would guess from the trends we see in the two studies that the corticosteroids are probably the more effective, and if I had a very severe sore throat that's what I'd take. But a milder sore throat, I'd probably just take the over-the-counter Nurofen.

Norman Swan: And Nurofen is more effective than paracetamol?

Paul Glasziou: It looks like it. Again, limited head-to-head information, but the anti-inflammatory effect that you get is in addition to the pain relief...so you get both if you're taking an anti-inflammatory. And that's all you're getting with the corticosteroids of course, you're getting no direct pain relief as you would with Panadol or paracetamol.

Norman Swan: And is there any evidence for things like honey?

Paul Glasziou: In our overall review we didn't find any. We did find some for caffeine.

Norman Swan: What happens with caffeine?

Paul Glasziou: Caffeine seems to give some pain relief as well. So remember they used to put caffeine in some of the old things like Bex, the combination pain relief, that seems to add something to it.

Norman Swan: So gargle with a latte.

Paul Glasziou: Yes!

Norman Swan: How do you know whether antibiotics are in fact needed?

Paul Glasziou: Well, the major reason for giving antibiotics isn't the pain relief, because they are not the most effective thing. Why you are giving antibiotics is to prevent the complications of a sore throat, and the complications that we are worried about can be categorised into two things. One is the so-called suppurative ones, that's things like getting an abscess in the back of your throat is one example of it, and antibiotics are effective at reducing that.

The one that we worry about most is the so-called rheumatic complications, but they are incredibly rare in the well-to-do standard Australian population. In some Aboriginal populations still there are high rates of rheumatic fever, and there you would probably want to cover the bacterial infection when it looks like it. And there are some features that suggest it's a bacterial infection. The standard criteria are that you don't have a cough and a runny nose which suggests that it's viral, but you do have a very sore throat, it's got pus on the throat, that you've got raised lymph nodes and you've got a high fever. So if you've got those sorts of features, that suggests that it may be bacterial. But even then, depending on the number of those features that you have, probably about 50% are still viral.

Norman Swan: So the statistics then still are of all comers with sore throats, it's only 10% or 15% are actually bacterial and merit an antibiotic. So if you just give an antibiotic blind to all comers, you're wasting 80% to 90% of your antibiotics.

Paul Glasziou: That's right, which is inducing antibiotic resistance in the population, so it's not a good thing to do.

Norman Swan: And then you can you can get a little bit better by using those clinical features you just mentioned.

Paul Glasziou: That's right, you can still up it. And you can up it even further. Within the UK they are looking into the near-patient testing, you can have these dipstick things where they can test instantly whether you've got a streptococcal sore throat or not and target it even further, and I think it would be worth looking at that because we are over-using our antibiotics, and trying to decrease the use would be a good thing, because the really good news about antibiotic resistance is that it is reversible. If we could get the population and doctors to use less antibiotics, we could gain back the antibiotics where we've developed resistance.

Norman Swan: Paul Glasziou is Professor of Evidence-Based Practice at Bond University in Queensland. And that study was published in the Cochrane Library; the reference will be on our website.

You're listening to the Health Report here on RN with me, Norman Swan.

Stephen Mason :

09 Dec 2012 8:02:43pm

I'm appalled by this suggestion. Corticosteroids should be reserved for severe inflammatory conditions where the inflammation is itself a threat to general health. Corticosteroids have long lasting side effects. To use them for sypmtomatic relief of mild pain (especially in children) is grossly irresponsible.